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• <br /> { <br /> Washington State STOP Formula Grant Program Renewal Application for FP/2019 <br /> CONFIDENTIALITY AND PERSONALLY IDENTIFYING INFORMATION <br /> (Victim Services Providers Only) <br /> Requirement to Comply,with,the Confidentiality and Privacy Provisions of VAWA for Victim Services <br /> Community-based victim service providers providing direct services to victims are required to comply <br /> with the provisions of 34 U.S.C. 12291(b)(2),nondisclosure of confidential or private information, <br /> which includes creating and maintaining documentation of compliance,such as policies and <br /> procedures for release of victim information. Frequently Asked Questions(FAQs)on the VAWA <br /> Confidentiality Provision can be found here.Applicants unable to comply with the statutory eligibility <br /> requirements of confidentiality will be prohibited from receiving these funds. <br /> In addition to completing the form Acknowledgement of Notice,of::Statutory Requirement to Comply <br /> with the Confidentiality and Privacy Provisions of the Violence AgainstWomen Act,as Amended, <br /> please respond to the questions below: <br /> Policy and Procedures on Breach of Confidentiality <br /> Does your organization have the following: <br /> 1. A policy/procedurepon notification to victims when a breach of confidentiality has occurred? <br /> Yes 0 No <br /> 2. A policy/procedure to notify the authorized representative of the award,who will be identified on <br /> the ace Sheet of your grant, no later than 24 hours after an occurrence of a breach? <br /> ® Yes CI No <br /> 3. A policy/procedure to report to the authorized representative of the award the circumstances of <br /> the each and how your organization will address it to prevent it from happening again? <br /> Yes ® No <br /> As the duly authorized representative of the applicant, I hereby certify that the above is true and correct. <br /> • <br /> S-_ ature o ge -r s _.i liceqV Official <br /> 24 pr <br /> 84 <br />